the psychology of paranoid delusions - intar.org
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The Psychology of Paranoid Delusions
Richard Bentall
Institute of Psychology, Health & SocietyLiverpool University
1: Defining delusions and the phenomenology of paranoia
Delusions are……
Bizarre or unusual beliefs. However, defining what makes a
particular belief delusional has taxed the minds of the greatest
psychopathologists…..
Karl Jaspers (1883-1960) argued that the
abnormal beliefs of psychiatric patients are
bizarre, resistant to counter-argument and held
with extraordinary conviction. However, true
delusions are also ununderstandable:
They cannot be understood in terms of
The patient’s personality
The patient’s experiences
And can therefore only be explained in terms of
aberrant biology.
Understandability
Berrios (1991): delusions are “empty speech acts, whose
informational content refers to neither world or self”.
DSM-IV (APA, 1994) defines a delusion as:
“A false personal belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person’s culture or subculture.”
A modern definition
Persecutory (paranoid) delusions
PANSS* > 2 N/255 %
Delusions (P1) 250 98
Suspicion (P6) 235 91.8
Delusions & Suspicion 230 90.2
Hallucinations (P3) 177 69.1
Thought disorder (P2) 144 56.5
Grandiosity (P5) 98 38.6
Agitation (P4) 179 70.2
Hostility (P7) 97 37.9
In the SoCRATES first episode sample (Moutoussis et al. 2007)
Positive and Negative Syndromes Scale (Kay et al., 1987), a widely used measure of
psychotic symptoms,
A paranoid continuum?
Many psychologists have argued that psychotic experiences exist on a
contiuum with normal functioning (e.g. Claridge, 1990) and have
developed psychometric instruments to assess this continuum (e.g.
Bentall, Claridge & Slade, 1988),
• Epidemiological studies show that large numbers of people
report delusional beliefs (12.0%, van Os et al., 2000, Holland) or
paranoia (12.6% paranoia, Poulton et al., 2000, New Zealand)
•Freeman et al. (2005) administered a paranoia questionnaire to
over 1000 people in a UK internet survey. They found evidence
for a continuum, although extreme beliefs about threats of harm
were only endorsed by a minority.
A paranoid continuum?
Proportion of population scoring on the Paranoia Checklist (from
Freeman et al. 2005).
A paranoid continuum?
Hierarchy of paranoia (from Freeman et al. 2005).
Two types of paranoia?
• Trower and Chadwick (1995) argue that there are two types of paranoia:
‘Poor me’ paranoia (persecution underserved, self-esteem preserved)
‘Bad me’ paranoia (persecution deserved, self-esteem low)
• However, there has been almost no research to examine the distinction.
The PADS (Melo et al., 2009)
Developed a Persecution and Deservedness scale (10, 12 and 20 item
versions) designed for both patient and clinical participants.
Administered to 312 undergraduates and 45 acutely psychotic patients.
1. There are times when I worry that others might be plotting
against me.
(ANS: 0 = certainly false; 4 = certainly true)
If you’ve answered 2 or above to the last question, please answer to
the following question:
1.1 Do you feel like you deserve others to plot against you?
(ANS: 0 = not at all; 4 = very much)
01
23
4
Deserv
edness
0 1 2 3 4
Paranoia
Students 95% CI
Patients 95% CI
The PADS (Melo et al., 2009)
Adequate reliability was found for both dimensions. In non-patients, a clear relationship was observed between paranoia and deservedness, but this relationship was absent in patients. In the patient sample, deservedness scores appeared to be suppressed.
Collip, Oorschot, Thewissen, Van Os, Bentall & Myin-
Germeys (2010)
Used a diary method (Experience Sampling) to examine variation of momentary paranoia and perceived social threat (“In this company I feel threatened”, “In this company I feel accepted” [reversed]) with social context:
whether alone, in unfamiliar company, in familiar company
subjective stress since last bleep
At low and moderate levels of trait paranoia (Fenigstein scale),paranoid thinking and perceived social threat were predicted by both context and subjective stress.
At high levels of trait paranoia, paranoid thinking and perceived social threat were NOT predicted by either context and subjective stress.
Fluctuations in deservedness (Melo et al., 2006)
43 paranoid patients compared with 22 healthy controls.
Initial intention was to repeat assessments of paranoid patients
after 1 month – proved difficult.
All patients completed a deservedness analogue scale on each
assessment “0 = I don’t deserve to be persecuted”; “12 = I deserve
to be persecuted”.
Fluctuations in deservedness (Udachina et al. in
press)
02
46
8D
eserv
edness
poor-me bad-me
6 7 102337414548778586437589 202529324751396974173056408466
ESM study with 14 PM and 15 BM patients. Deservedness
measured at each beep.
Time
Des
erved
nes
sTime course of deservedness?
Bad me
Poor me
Bad me
Poor me
Prodrome First episode
2: Evolutionary and developmental origins of paranoia
In the conditioned avoidance paradigm, the animal is placed in a shuttle box, in
which it can receive a warning signal and an electric shock.
All organisms need a system for anticipating and avoiding
threat
Aversive SAversive S EscapeEscapeWarning SWarning S
Avoidance RAvoidance RNo aversive SNo aversive SWarning SWarning S
Note that learning
continues (decreased
response latencies) long
after 100% avoidance is
achieved.
Does repeated exposure to threat lead to
psychosis?: A meta-analysis
Initial database search found 27,572 hits- after excluding studies based of inspection of the papers' titles and abstracts, the 763 remaining papers were examined for inclusion.
The analysis refers to studies focusing on EARLY adversity (exposure to trauma, bullying, parental death etc before the age of 18) and psychosis (both diagnostic and dimensional outcomes) with the following designs:
• epidemiological cross-sectional studies• prospective studies (and quasi prospective studies)• patient control studies
Study name Odds ratio and 95% CI
Bebbington et al., 2011 Epidemiological cross-sectional
Harley et al., 2010 Epidemiological cross-sectional
McAloney et al., 2009 Epidemiological cross-sectional
Nishida et al., 2008 Epidemiological cross-sectional
Shevlin et al., 2008 Epidemiological cross-sectional
Whitfield et al., 2005 Epidemiological cross-sectional
Epidemiological cross-sectional
Evans, 2011 Patient-control
Fisher et al., 2010 Patient-control
Habets et al., 2011 Patient-control
Husted et al., 2010 Patient-control
Rubino et al., 2009 Patient-control
Sommer et al., 2010 Patient-control
Stompe et al., 2006 Patient-control
Varese et al., 2011 Patient-control
Weber et al., 2008 Patient-control
Patient-control
Arseneault et al., 2010 Prospective (and quasi-prospective)
Cutjar et al., 2010 (M) Prospective (and quasi-prospective)
Cutjar et al., 2010 (F) Prospective (and quasi-prospective)
De Loore et al., 2007 Prospective (and quasi-prospective)
Schreier et al., 2009 Prospective (and quasi-prospective)
Spauwen et al., 2006 Prospective (and quasi-prospective)
Prospective (and quasi-prospective)
0.01 0.1 1 10 100
Increased likelihood
Association between trauma and psychosis
The findings suggest a significant association between trauma and psychosis across all different reserach designs (patient-control studies:
• patient-control studies: OR = 3.3
• epidemiological cross-sectional: OR = 2.5
• prospective: OR = 2.6
Does repeated exposure to threat lead to
psychosis?: A meta-analysis
Is there a specific association between victimization
and paranoia?
Mirowski and Ross (1981) reported data on paranoid beliefs from a
community survey of residents of El Paso and Juarez. Paranoia was
associated with an external locus of control and experiences of
victimization and powerlessness.
The high risk of psychosis in immigrant groups (Harrison et al.,
1988), especially those living in relative isolation from other
immigrants (Boydell et al. 2001) might be explained in this way.
Janssen et al. (2003), in an epidemiological study of 7000+ Dutch
citizens, found that experiences of discrimination predicted the later
development of paranoid symptoms.
Attachment: A developmental vulnerability?
Dozier at al. (1991, 1995) found that schizophrenia patients,
especially with paranoia, most likely to have dismissing-avoidant
attachment style.
Community surveys of 8000 adults (Mickleson et al., 1997) and
1500 adolescents (Cooper at al., 1998) also show psychosis,
especially paranoia, associated with insecure attachment.
Early separation from parents (Morgan et al. 2006) and being
unwanted at birth (Myhrman et al. 1996) increase the risk of
psychosis in later life.
Pickering, Simpson & Bentall (2008)
503 students completed online questionnaires:
• The PADS (Melo et al. in press)
• The Launay–Slade (1981) Hallucination Scale
• Bartholomew and Horowitz’s (1991) Relationship Questionnaire
• Levenson’s multidimensional locus of control scale
(Externality, Chance, Powerful Others)
• Positive and negative self-esteem (Nugent & Thomas, 1993)
• Anticipation of threatening events (Bentall et al. in press)
Insecure attachment predicted paranoia when hallucinations were controlled for:
R2 = .53, for model including attachment anxiety, negative self-esteem,
anticipation of future threat, the recall of threat and powerful others
Insecure attachment did not predict hallucinations when paranoia was controlled for.
Specificity of adversities for paranoia
Data from the 2007 Adult Psychiatric Morbidity Survey (N =
7000+), which has measures of psychotic symptoms, and different
kinds of childhood adversity.
3: Psychological mechanisms
Psychological processes that have been implicated
in paranoia
Jumping to conclusions (e.g. Garety et al. 2001):
Patients with delusions tend to ‘jump to conclusions’ (make a decision about
uncertain events) on the basis of little information
• Typically measured by ‘the beads task’
• Well replicated finding
• Seems to be associated with delusions rather than specifically paranoia
Jumping to conclusions bias
Huq, Garety & Hemsley (1988)
Participants shown 2 jars with beads of two colours,
in ratios of 80:20 and 20:80. A sequence of beads is
shown, apparently from one of the jars. Participants
had to guess which jar.
Participants with delusions tended to ‘jump to
conclusions’, guessing after fewer draws. Although
well-replicated (Young & Bentall, 1997)
Psychological processes that have been implicated
in paranoia
Jumping to conclusions (e.g. Garety et al. 2001):
Patients with delusions tend to ‘jump to conclusions’ (make a decision about
uncertain events) on the basis of little information
• Typically measured by ‘the beads task’
• Well replicated finding
• Seems to be associated with delusions rather than specifically paranoia
Theory of mind (e.g. Corcoran & Frith, 1996):
It has been argued that paranoid patients have difficulty in understanding other
people’s thoughts and feelings (they have a poor ‘theory of mind’)
• Assessed by false belief stories, hinting tasks or even appreciation of jokes
• Psychotic patients perform poorly on ToM tasks, but specificity to
paranoia is ot proven
Attributions (e.g. Kaney & Bentall, 1989):
People make explanations (‘attributions’) for noteworthy events many times in a single day. ‘Attributional style’ refers to individual differences in the way that we construct explanations. Eg. from the Attributional Style Questionnaire (ASQ):
You fail an exam. Write down one possible cause__________________
InternalInternal
Totally due to me
StableStable
I can’t change it
Unstable
I can change it
External
Due to others or
circumstances
GlobalGlobal
It will affect all areas of my life
Specific
It will only affect
examinations
Attributional (Explanatory) Style
Positive Negative
ParanoidDepressedNormal
Fundamental observation:Paranoid patients makeabnormal attributions
Internality Scores*
10
20
30
40
Eg. Kaney & Bentall (1989)using the ASQ, found thatparanoid patients madeexcessively stable and globalattributions for negativeevents. More importantly,they showed an extremeself-serving bias.
Attributional (Explanatory) Style
* High scores mean
self-blaming, low
scores mean the cause
is something to do
with other people or
circumstances.
3 loci of causal attribution?
Research suggests that the bipolar internality scale of Peterson et al's (1982) ASQ:
is in need of revision. Kinderman & Bentall (1996) have suggested a three-way categorization of the internality dimension :
Internal
Totally due to me
External
Personal
External
Situational
External
Totally due to other people or
circumstances
Internal Totally due to me
Totally due to another person
or other people
Totally due to the situation
(circumstances or chance)
Kinderman & Bentall (1997) examined the tendency to makefewer internalattributions for negative events, and the tendency to make personal as opposedto situational external attributions in paranoid, depressedand non-patientparticipants.
2
3
4
5
6
7
8
9
10
Paranoid
Depressed
Non-patient
Attributional loci
Internal Personal Situational
+ - + - + -
3 loci of causal attribution?
The original attributional model
Bentall, Kinderman & Kaney (1994) proposed that an externalizingattributional style minimizes accessibility of negative self-schemas at the expense of generating paranoid beliefs.
External (other-blaming) attribution
Reduced negative thoughts about self
Threat of activation of negative beliefs about self
Increased belief that others have malevolent intentions towards self.
Experimental Group
Depression (Younger)
Depression w
P.D
elus
Control
Rem
itted Paranoid
Paranoid
Mean
110
100
90
80
70
60
50
40
30
Neg self-esteem
Pos self-esteem
Wellcome Paranoia Study: Schizophrenic paranoid (N=38), remitted schizophrenic paranoid (N=27), depressed paranoid (N=18), depressed non-psychotic (N=27) and control participants (N=33) (Bentall et al., in press.)
Correlations between
negative self-esteem &
paranoia (Fenigstein Scale)
Spearman r
SZ-P .32
SZ-R .41*
DEP-P .42
DEP-NP .53*
Control .39*
Problem #1: The relationship between self-esteem and paranoia (Bentall et al., 2008)
• Patients with positive psychotic symptoms (n=79), individuals with an at-risk mental state for paranoid psychosis (n=38), and control subjects (n=38) assessed using experience sampling method (ESM).
• 6 day diary, 10 bleeps/day:– 4 items measuring momentary self-esteem
– Other items measuring context, significant
experiences and attributions
Thewissen, Bentall, Lecomte, van Os & Myin-Germeys
(2008)
Thewissen, Bentall, Lecomte, van Os & Myin-Germeys
(2008)
SE instability Confounders n β (SE) p
Momentary level 1 -
sex, depression
sex, depression, SE level
155
155
155
.11 (.03)
.10 (.03)
.09 (.03)
p<.001
p<.01
p<.01
Day level 1 -
sex, depression
sex, depression, SE level
155
155
155
.21 (.06)
.20 (.07)
.17 (.07)
p<.01
p<.01
p=.01
Subject level 2 -
sex, depression
sex, depression, SE level
155
155
155
.13 (.03)
.13 (.04)
.11 (.03)
p<.001
p<.001
p<.01
Paranoia was associated with average low self-esteem, an effect that survived correction for depression but not SE instability. More importantly paranoia also independently related to SE stability:
1 Multilevel linear random regression model, β can be interpreted identically to the regression outcome in a unilevel linear regression model.
2 Unilevel linear regression model * p<0.05; ** p<.01; *** p<.001
Fluctuations and PM vs BM (Udachina et al. in
prep)
ESM study with 14 PM and 15 BM patients. 15 remitted patients
and 23 controls also assessed. Self-esteem and deservedness
measured at each beep.
• Deservedness was predicted by concurrent self-esteem.
• Onset of paranoia was predicted by drop in self-esteem from the
previous bleep.
• In BM patients, increases in paranoia were followed by decreases
in self-esteem at the next beep.
• In PM patients, remitted patients and controls, increases in
paranoia were followed by increases in self-esteem at the next beep.
Grey, Evans, Valiente & Bentall (in prep)
Two studies have reported that paranoid patients sometimes show low implicit self-esteem but relatively preserved explicit self-esteem (Moritz & Woodward, 2005; McKay et al. 2005). We measured implicit (Implicit Attitudes Test) vs explicit SE (Nugent & Thomas’s scale) in poor-me patients, bad-me patients and controls.
PM = BM < C All groups sig different
Associations between attributions and clinical paranoia have a ‘now-you-see-it, now-you-don’t’ aspect:
Replications:
• Candido & Romney (1990) (Canada)
• Fear et al. (1996) (Wales)
• Lassar & Debbelt (1998) (Germany)
• Lee & Wong (1998) (South Korea)
Partial replications:• Kristev et al. (1999) (Australia; partial replication)• Martin & Penn (2002)• McKay et al. (2005)
Problem #2: Is the association between attributions and paranoia replicable?
Complete failures to replicate:• Humphries and Barrowclough (2006)
Attributional abnormalities present in acute paranoid but not ‘normal’ paranoids• Jannsen et al (2006)• McKay et al. (2005)• Martin & Penn (2001 – non-patients) vs Martin & Penn (2002 – patients)
Attributions and deservedness (Melo et al., 2006)
p < .001
p < .01
* Low attribution scores indicate external attributions for negative events
Take home message from Part 3
• Negative self-esteem seems to be a very important factor in
paranoia.
• Excessively external attributions for negative events are only
found in acutely ill poor-me patients when they are ‘poor me’
• Self-esteem is also highly unstable in paranoia (possibly
relating the dynamic transitions between poor-me and bad-me
beliefs)
• Poor me paranoia is also associated with discrepancies
between implicit and explicit self-esteem.
4: Are all of the theories correct?
Must everyone get prizes?
In our recent Wellcome Trust funded study we combined data from the
following groups (Bentall et al. 2009):
• Schizophrenia patients with paranoid delusions
• Schizophrenia patients with paranoid delusions in remission
• Depressed patients with paranoid delusions
• Depressed patients without paranoid delusions
• Patient with late onset (aged => 65) schizophrenia-like psychosis with
paranoid delusions
• Elderly (aged => 65) depressed patients without paranoid delusions
• Healthy controls
Must everyone get prizes?
And modelled the relationships between measures of:
• Paranoid beliefs
• Threat anticipation
•Attributional style (excluding internality)
• Self-esteem (positive and negative)
• Depression and anxiety
• Theory of mind (2 measures)
• Jumping to conclusions (2 measures)
• Cognitive (executive) function (short WAIS and digit span backwards)
Could all of these theories be true?
Structural equation modelling revealed the following relationships:
THR1 THR2 THR3 THR5THR4 THR6 THR7
DFO1 DFO2 DFO3
GLOB
STAB
ST1
GL1
ST2
ST3
ST4
ST5
ST6
GL2
GL3
GL4
GL5
GL6
EMDYS
ANX DEP SEp SEn
INTFUN
IQv IQm DIGIT
ANTICPARB
ToMD
PDI2
PDI3
PDI4
PDI1
JTC
BIJ1
BIJ2
BIJ3
SOC1
SOC2
SOC3
.65 .81 .66.62 .68.80
.38
.59
.48
.46
.55
.70
.42
.55
.53
.42
.38
.58.97
.95
.92
.76
.87 .71 -.62 .92
.72
.78
.60
.46
.82
.60 .87 .93 .70 .64 .65 .55
.84
.90
.78
.92
.92
.88
PARCOG_P DEP_S
.92 .85
.72
-.39 .68
-.07
.25
.02
.17
.08
.22
.17
DSO2
DSO1
DSO3
.86
.32
.55
Could all of these theories be true?
Structural equation modelling revealed the following relationships:
Globality
Stability
Negative
emotionExec
function
Threat
AnPDI
ToM
JTC
.72
.78
.60
.46
.82
ParanoiaCognitive
Perfom.
pessimism
.92 .85
.72
-.39 .68
-.07
Take home message from Part 4
• There is evidence to support the role of multiple psychological
processes in paranoia
• These can be broadly grouped into two classes: emotional
(self-esteem and attributions) and cognitive (executive
function?)
• Emotional factors seem to be more important
• BUT the idea of a paranoid defence seems to still have some
mileage with respect to poor-me delusions in acutely ill patients
5: Some biological speculations
The animal is placed in a shuttle box, in which it can receive a warning signal and
an electric shock.
The conditioned avoidance paradigm
Aversive SAversive S EscapeEscapeWarning SWarning S
Avoidance RAvoidance RNo aversive SNo aversive SWarning SWarning S
Note that learning
continues (decreased
response latencies) long
after 100% avoidance is
achieved.
Could attributional responses seen in poor-me paranoia be
construed as covert avoidance responses?
Aversive
emotional state
Aversive
emotional stateNegative
thought
Negative
thought
External
attribution
External
attributionNo aversive
emotional state
No aversive
emotional state
Negative
thought
Negative
thought
How does CAR relate to paranoia?
Dopamine-blocking drugs abolish the conditioned avoidance
response (CAR) in animals (Beninger et al., 1980; Smith et al. 2005),
but not escape responding – suggests a role for dopamine in threat
perception. Hence, the CAR has long been used as initial screen for
antipsychotic drug action.
The CAR and dopamine
Drugs which block d-2 receptors in the striatum have a powerful
therapeutic effect on patients who experience persecutory delusions.
Animal studies show that repeated exposure to social defeat in animals
leads to sensitization of the dopamine system (Selten, 2005).
Paranoia as the end point of a developmental
pathway
Threat
anticipation
Threat
anticipation ParanoiaParanoia
Victimisation/
powerlessness
Victimisation/
powerlessness
Insecure
attachment
Insecure
attachment
Abnormal
cognitive style
Abnormal
cognitive style
Psychological description:
Paranoia as the end point of a developmental
pathway
Abnormal
dopamine
Abnormal
dopamine ParanoiaParanoia
Victimisation/
powerlessness
Victimisation/
powerlessness
Insecure
attachment
Insecure
attachment
Abnormal
cognitive style
Abnormal
cognitive style
Biological description:
Conclusions
• There seems to be a discontinuity between moderate and
severe paranoia
Moderate Paranoid Severe Paranoia
Type of delusion Bad-me Poor-me, but switching to
bad-me
Context dependency Dependent Independent
Self-esteem
Implicit Low Low
Explicit Low Higher
Stability Less unstable Highly unstable
Attributions Normal External for negative
events
Biological mediator ? Hyper-dopaminergia?
Antipsychotic responsive No Yes
Conclusions
• It is possible that the biological mediator of some of these processes
is the striatal dopamine system
• Abnormal cognitive functioning, leading to paranoid ideas, many
be the consequence of particular types of adverse life experiences
(insecure attachment and victimization).
• Paranoia can be explained in terms of the interaction between a
relatively small number of cognitive and emotional processes
• Genetic speculation (possibly naive): The A1 allele of the DRD2 gene
is associated with lower striatal D2 receptor density and poor
avoidance learning (Klein et al. 2007) - it should therefore be
protective against paranoia!
Clinical implications and further directions
• It seems likely (but not certain at this stage) that transition to
psychosis from the prodromal state is associated with a switch
from bad-me to poor-me. Consistent with this, we have found
that low self-discrepancies (good self-esteem) is positively
associated with psychosis in a prodromal sample (Morrison et
al. 2006).
• We can hypothesize that the shift from bad-me to poor-me on
transition to psychosis (if it occurs) is a result of attempts to
avoid negative thoughts (consistent with the assumptions
behind Bach & Hayes’ (2002) Acceptance and Commitment
Therapy version of CBT for psychosis)
• This conjecture needs to be tested in future studies:
- Longitudinal investigations of deservedness beliefs and
avoidance behaviours in high risk samples
- Experimental, genetic and neuroimaging studies of
avoidance learning in clinical samples
- Tests of new psychological interventions designed to
prevent abnormal avoidance behaviour.
Implications and further directions
That’s all folks!